Association of implementation of secondary fracture prevention incentives after hip fracture and risk of subsequent fracture in real-world practice.

PURPOSE: Secondary fracture prevention (SFP) after hip fracture is recommended in clinical guidelines but implementation remains suboptimal in routine practice. Financial incentives linked to SFP management have been introduced to address implementation gaps; however, whether such strategies reduce subsequent fractures in routine practice remains unclear. We evaluated the association between receipt of SFP incentives and subsequent fractures and explored factors associated with implementation. METHODS: This nationwide retrospective cohort study using Japanese administrative claims data included 11,147 patients aged 60 years or older who underwent hip fracture surgery. The primary outcome was major osteoporotic fracture within 12 months, analyzed using Fine-Gray models accounting for the competing risk of death. Facility-level factors associated with acute-care incentive billing were examined using multilevel Poisson regression. RESULTS: Overall, 4,019 patients (36.1%) received acute-care SFP incentives during the index hospitalization. Receipt of the acute-care incentive was associated with a 15% lower risk of subsequent fractures (subdistribution hazard ratio, 0.85; 95% confidence interval, 0.73 to 0.99). Incentive uptake was associated with hospital-level characteristics reflecting prior osteoporosis care performance, including Diagnosis Procedure Combination participation (risk ratio, 2.11; 95% confidence interval, 1.45 to 3.08) and higher prior-year osteoporosis assessment rates. Continuity of post-discharge management was limited: 66.0% of recipients had no subsequent incentive claims, and cumulative post-discharge claims were not associated with additional fracture risk reduction. CONCLUSION: Acute-care SFP incentives were associated with lower fracture risk in routine practice, but implementation and continuity were suboptimal, highlighting the need to improve SFP implementation across the post-fracture care pathway.